Retrospective review

AFMC reviews a random sample selection of Medicaid inpatient hospital stays for medical necessity of all paid days, quality of care, and billing errors. This random sample selection is made from paid claims data on a monthly basis and a case review listing is sent to hospitals by the 5th of each month. Hospitals are asked to submit copies of the medical record for each of the selected cases via AFMC ReviewPoint®. Other methods of chart submission are available. Please call the AFMC Processing Department (479-573-7770) discuss other available options. Hospitals may submit paper chart copies, however, according to Medicaid, chart copying costs are figured into the hospital’s per diem reimbursement rate and no additional reimbursement for chart copies will be made.

If, during the initial review, it is determined that the hospital inpatient stay does not meet admission or length of stay screening criteria, or there is a quality of care concern, the case is referred for physician review.

AFMC is frequently asked why cases are reviewed months after the admission occurred. There are many reasons why hospitals do not file claims as soon as the patient is discharged; however, AFMC selects cases for review from the claims paid in the previous month.

Notice of adverse actions, reconsideration, appeals and hearings

If AFMC is unable to fully approve any requested service, all applicable parties are notified in writing of the review determination along with detailed instructions on how to request an appeal.

Reconsideration

The provider then has 30 calendar days from the date of the AFMC denial letter to request reconsideration of the denial. If the initial denial is upheld on reconsideration or if reconsideration is not requested within the required timeframe, AFMC notifies Medicaid of the denial to determine if recoupment of the money that had been paid for the claim is required.

Fair hearing requests

The Medicaid beneficiary may request a fair hearing of a denied review determination made by either the Utilization Review Department of Human Services (DHS) or AFMC. The fair hearing request must be in writing and sent to the Appeals and Hearings Section of DHS within 35 calendar days of the date on the denial letter.

How to protect yourself

AFMC will protect your privacy as described in this Privacy Statement, however, you should keep in mind that if you voluntarily disclose personal information, especially confidential health information, it is possible that despite our efforts, information may be accessible by others. You can help guard against this by: